ADULT HEALTH. IMMUNE
The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply. 1) Avoid annual influenza vaccination 2) avoid situations that cause physical and emotional stress. 3)Avoid sun exposure and UV light when possible. 4) Notify the HCP if you have fever. 5) Use antibiotic soap to cleanse skin rashes.
2, 3, 4 Systemic lupus erythematosus (SLE) is an autoimmune disorder (the body's immune system erroneously attacks body tissues) that results in inflammation and damage to many body parts. Symptoms vary widely among affected individuals, but most experience painful/swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time (called flares) alternating with periods of remission. There is no cure for SLE, but it can be treated with immunosuppressants (eg, corticosteroids) or immunomodulators (eg, hydroxychloroquine). Pneumonia and annual influenza vaccinations are recommended for those with SLE as they are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their health care provider (Options 1 and 4). Both physical and emotional stress can exacerbate SLE. Therefore, clients should follow a healthy lifestyle (eg, 7-8 hours of sleep, no smoking). Balanced exercise with alternating periods of rest is recommended (Option 2). Sunlight is known to worsen the rash of SLE and should be avoided when possible (especially between 10 AM-4 PM); protective clothing and sunscreen application are recommended during periods of sun exposure (Option 3). (Option 5) The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided. The rash is not due to bacterial infection. Educational objective: Clients with SLE should be advised to avoid harsh sunlight and ultraviolet light exposure as well as harsh soaps and chemicals. These clients often receive corticosteroids and are susceptible to infection; therefore, annual influenza vaccination (eg, killed vaccines) is important.
A client allergic to bee stings was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate actions? Select all that apply. Vital signs Blood pressure 92/40 mm Hg Apical pulse 140/min and regular Respirations 36/min and labored Oxygen saturation 89% Admission notes 14:00 Diaphoretic; urticaria noted on upper extremities and torso. Bilateral inspiratory and expiratory wheezing on auscultation. Notes "chest tightness, trouble breathing, and itching." __________, RN 1) Inhaled albuterol 2) IM epinephrine 3) IV methylprednisolone 4) IV metoprolol 5) IV nitroglycerine
1, 2, 3 Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). It is caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Anaphylactic shock results in hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. The management of anaphylactic shock includes: Call for help (activate emergency management systems) - first action Maintain airway and breathing - administer high-flow O2 via non-rebreather mask Epinephrine, intramuscular - the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response. Elevate the legs Volume resuscitation with IV fluids Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction (Option 4) Metoprolol (beta blocker) should not be given as the blood pressure is already low. (Option 5) Nitroglycerine would also cause hypotension and should not be given. Morphine is avoided as it can worsen pruritus and hypotension. Educational objective: Diphenhydramine (Benadryl), IM epinephrine, inhaled beta agonists, and methylprednisolone (Solu-Medrol) are administered to treat the manifestations associated with anaphylactic shock. They modify the histamine response and treat pruritus, reverse bronchoconstriction, and decrease airway inflammation, respectively. IM epinephrine can be repeated for poor response.
The clinic nurse performs an admission assessment on a client diagnosed with systemic lupus erythematosus (SLE). Which characteristic cutaneous manifestation of SLE would the nurse most likely assess? 1) butterfly sape rash 2) petechiae 3) pruritus 4) urticaria
1) SLE is an autoimmune disorder in which the body's immune system produces autoantibodies that attack the body's tissues and cells. It is characterized by alternating periods of exacerbation (flare) and remission. The skin is one of the target organs commonly affected by the disease. The characteristic cutaneous manifestation of SLE (> 50%) is a flat or raised red rash that forms a butterfly shape across the bridge of the nose and cheeks. It is often related to sunlight exposure (ultraviolet light) and is more pronounced during a disease flare (Option 1). Recurrent oral ulcers are also very common. (Options 2, 3, and 4) Although petechiae, pruritus, and urticaria may be associated cutaneous manifestations, they are not characteristic specifically to SLE. Educational objective: The characteristic cutaneous manifestation of SLE is a flat or raised red rash that forms a butterfly shape across the bridge of the nose and cheeks.
The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1) Abrupt onset htn and headache 2) blue and cold fingertips 3) dry cough and exertional dyspnea 4) heartburn and difficulty swallowing
1) Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. (Option 2) Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening. (Option 3) Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening. (Option 4) Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma. This is due to the disease process of internal scarring, and it is not life-threatening. Educational objective: Scleroderma is caused by collagen overproduction; it is a lifelong disease without a cure. Treatment is aimed at controlling symptoms and preventing further complications. Renal crisis is life-threatening and should be recognized and treated immediately.
A clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome? 1) dry eyes and mouth 2) low back stiffness 3) multiple tender joints 4) thickening of the skin
1) Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help (Option 1). (Option 2) Early-morning low back stiffness is seen with ankylosing spondylitis. (Option 3) Multiple tender points are characteristic of fibromyalgia. (Option 4) Thickening of the skin is seen with scleroderma. Educational objective: Sjögren's syndrome is an autoimmune condition that can cause dry eyes and mouth. Clients are instructed to use artificial tears and saliva.
The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus. Which result is of greatest concern and prompts the nurse to notify the health care provider? 1) Creatinine of 1.8 mg/dL 2) elevated erythrocyte sedimentation rate 3) Positive antinuclear antibody titer 4) WBC of 2,600/mm3
1) Systemic lupus erythematosus (SLE) is an autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body. SLE ranges in severity from mild (eg, affecting skin, muscles, joints) to severe (eg, affecting kidneys, heart, lung, blood vessels, central nervous system) disease. Increased creatinine (normal 0.6-1.3 mg/dL [53-115 µmol/L]), increased blood urea nitrogen (normal 6-20 mg/dL [2.1-7.1 mmol/L]), and an abnormal urinalysis (eg, protein, red blood cells, cellular casts) can indicate the presence of lupus nephritis (occurring in 50%), a potentially serious complication of SLE. Early recognition and aggressive immunosuppressive treatment are essential to preserve renal function and prevent irreversible kidney damage (Option 1). (Option 2) An elevated erythrocyte sedimentation rate (normal <30 mm/hr) can indicate the presence of an active inflammatory process and would be expected in a client with an inflammatory disease such as SLE, especially during a disease flare. This is nonspecific and does not give information as to which organ is being attacked by inflammation. (Option 3) A positive antinuclear antibody (ANA) titer (>1:40) indicates the presence of ANAs, which the body produces against it own DNA and nuclear material. This would be expected in a client diagnosed with SLE. (Option 4) Anemia, mild leukopenia (white blood cell count <4,000/mm3 [4.0×109/L]), and thrombocytopenia (platelet count <150,000/mm3 [150×109/L]) are often present in SLE. The nurse would report these to the health care provider, but they are not of greatest concern. Educational objective: Increased serum creatinine (>1.3 mg/dL [115 µmol/L]), increased blood urea nitrogen (>20 mg/dL [7.1 mmol/L]), and an abnormal urinalysis can indicate the presence of lupus nephritis, a potentially serious complication of SLE in which inflammation of the kidney can lead to renal injury. Early recognition and treatment are essential to preserve renal function and prevent irreversible kidney damage.
The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply. 1) Chewing sugar-free gum or using artificial saliva 2) scheduling regular dental examinations 3) showering with lukewarm water and avoiding harsh soaps 4) using OTC decongestants to alleviate nasal symptoms 5) using OTC lubricants to ease vaginal dryness
1, 2, 3, 5 Sjögren's syndrome is a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells. The most commonly affected glands are the salivary and lacrimal glands, leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Dryness in these areas can lead to corneal ulcerations, dental caries, and oral thrush. Other areas that can be affected and their symptoms include: Skin - dry skin and rashes Throat and bronchi - chronic dry cough Vagina - vaginal dryness and painful intercourse Treatment is focused on alleviating symptoms as there is currently no cure for Sjögren's syndrome. Over-the-counter or prescribed drops are used to relieve itching, burning, dryness, and gritty sensation in the eyes. Wearing goggles may offer further protection from drying caused by the wind. Dry mouth is treated with sugarless gum and candy or artificial saliva. Regular dental appointments to prevent dental caries are recommended. Lubricants (eg, K-Y Jelly) help to ease vaginal dryness. Use of lukewarm water and mild soap when showering can prevent dry skin. Avoiding low-humidity environments (eg, centrally heated houses, airplanes) and using humidifiers to maintain adequate humidity (mainly at night) are also recommended. (Option 4) Clients with Sjögren's syndrome are advised to avoid decongestants as they cause further dryness to the mouth and nasal mucosa. These clients should also avoid oral irritants (eg, coffee, alcohol, nicotine) and acidic drinks (eg, carbonated beverages, juices) and instead sip water frequently. Educational objective: Clients with Sjögren's syndrome need measures to combat the effects of damaged moisture-producing glands. These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.
A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply. 1) dyspnea 2) fever 3) lightheadedness 4) skin rash (hives) 5) wheezing
1, 3, 4, 5 The nurse should instruct the parent to first assess for signs of swelling of the mouth, tongue, lips, and upper airway. The child will have wheezing and difficulty breathing next, followed soon by cardiovascular symptoms. These include lightheadedness due to hypotension, loss of consciousness, and cardiovascular collapse. An anaphylactic reaction is life-threatening and requires rapid assessment and intervention. (Option 2) Fever is not a symptom of an anaphylactic reaction that would be included in the rapid assessment. Educational objective: Anaphylaxis is a medical emergency requiring rapid assessment and intervention. Symptoms of an anaphylactic reaction include signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).
The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD). The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)? 1) Lansoprazole 2) Metronidazole 3) Prednisone 4) Sulfasalazine
3) Tuberculosis is an infection caused by the Mycobacterium tuberculosis microorganism. A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a latent TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, cannot transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease. A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should notify the HCP. (Option 1) Lansoprazole (Prevacid) is a proton pump inhibitor used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease. It does not convert LTBI to active disease. (Option 2) Metronidazole (Flagyl) is an antimicrobial medication used to treat IBD and does not convert LTBI to active disease. (Option 4) Sulfasalazine (Azulfidine) is a gastrointestinal anti-inflammatory medication used to treat IBD and does not convert LTBI to active disease. Educational objective: A client with LTBI has a positive TST, is asymptomatic, and cannot transmit the disease to others. Malignancy, immunosuppressant medications, chemotherapy, and prolonged debilitating disease (eg, HIV) can convert LTBI to active disease.
The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply. 1) I use a soft-bristle toothbrush and mild mouth rinse. 2) I enjoy walking and wearing nonskid footwear for safety. 3) I use a safety razor and gentle shaving cream. 4) Sometimes I get constipated, so I have been taking docusate. 5) When I have a headache, I take OTC ibuprofen.
3, 5 Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109/L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes: Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1). Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes low-impact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2). Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding, and hemorrhoids (Option 4). (Option 3) Clients with ITP should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin. (Option 5) Clients with ITP should avoid nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen, ketorolac), which further impair platelet function. Acetaminophen and opiates are better options for pain management. Educational objective: Clients with immune thrombocytopenic purpura (ITP) have low platelet counts and an increased risk of bleeding. Appropriate care for clients with ITP includes safe exercise; using stool softeners, electric razors, and soft-bristle toothbrushes; and avoiding nonsteroidal anti-inflammatory drugs.
The nurse reviews the most current laboratory results of assigned clients. Which result should the nurse report to the health care provider immediately? 1) Client who has cellulitis of the leg with WBC of 13,000/mm3 2) Client who has chronic kidney injury with a hct of 28% and hgb of 9g/dL 3) Client who has type 2 DM with a 2 hour post prandial serum glucose of 165 mg/dL 4) CLient who is 1 month post kidney transplant with a urinalysis showing WBCs and bacteria
4) Almost all post kidney transplant clients are prescribed immunosuppressant drugs (eg, cyclosporine, azathioprine, prednisone) to help prevent organ rejection. This client's immunocompromised condition increases the risk for developing infection. Therefore, early recognition and prompt treatment of infection are critical to survival. The nurse should notify the health care provider (HCP) immediately of any signs or symptoms of an infection as well as abnormal urinalysis findings. (Option 1) Cellulitis is a bacterial infection (eg, Staphylococcus aureus, streptococci) that causes inflammation of the subcutaneous tissues. An increased WBC count (normal 4,000-11,000/mm3 [4.0-11.0 × 109/L]) would be expected in this client, so immediate notification of the HCP is not necessary. (Option 2) Clients with chronic kidney injury have a decreased level of the hormone erythropoietin, resulting in decreased erythrocyte production. Decreased hematocrit (normal 39%-50% [0.39-0.50] for males, 35%-47% [0.35-0.47] for females) and hemoglobin (normal 13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L for females) levels would be expected in this client, so immediate notification of the HCP is not necessary. (Option 3) An elevated postprandial serum glucose (>140 mg/dL [7.8 mmol/L]) would be expected in a client with type 2 diabetes mellitus, so immediate notification of the HCP is not necessary. Educational objective: Clients who have undergone kidney (or any organ) transplantation are prescribed immunosuppressant drugs to help prevent organ rejection and are therefore at increased risk for developing infection. The nurse should notify the HCP immediately of any signs or symptoms of an infection.
A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension, and shortness of breath. Place the nurse's subsequent actions in the correct order. All options must be used. 1) Administer diphenhydramine IV 2) Assess airway and place client on o2 3) Give IM epinephrine and start IV NS 4) Monitor VS for changes 5) Stop the infusion and call for help
5, 2, 3, 1, 4 Anaphylactic shock has an acute onset (20-30 minutes) caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs (eg, antibiotics), foods (eg, shellfish, peanuts), diagnostic agents (eg, contrast), biologic agents (eg, blood, vaccines), and venom (eg, bees, snakes) and results in circulatory failure, laryngeal edema, and severe bronchoconstriction. Management of anaphylactic shock includes: Stop the infusion that is causing the reaction and call for help (eg, rapid response team) (Option 5). Ensure patent airway, then administer oxygen via a high-flow nonrebreather mask and prepare for intubation if needed (Option 2). Give epinephrine intramuscularly. Epinephrine counteracts the effect of the histamines released, dilating bronchial smooth muscles and providing vasoconstriction. Most deaths from anaphylaxis are due to delaying epinephrine. Maintain blood pressure with normal saline IV fluid (Option 3). Administer adjunctive therapies: Bronchodilators (eg, albuterol) to dilate the small airways and reverse bronchoconstriction, antihistamines (eg, diphenhydramine) to modify the hypersensitivity reaction, and corticosteroids (eg, methylprednisolone) to decrease airway inflammation and swelling associated with the allergic reaction (Option 1). Continue to reassess vital signs for any changes (Option 4). Educational objective: In a client who is experiencing an anaphylactic reaction to an IV medication, it is imperative to first stop the infusion; ensure airway patency and administer oxygen; give epinephrine and initiate IV fluids; and administer adjunctive therapies (antihistamines, bronchodilators, corticosteroids).
